All About Rosacea

We all love a little bit of blush or rosy, red cheeks - but sometimes we can feel like the skin on our face is too red or warm. This can be caused be a condition called rosacea. This sensitive skin condition is extremely common, but it can be a difficult one to diagnosis in some patients.

So let’s learn the basics about what rosacea is, how it is triggered, how it can present, and what we can do about it.

What is rosacea?

Rosacea is a chronic condition, and unfortunately there is no cure for it. However, that does not mean there aren’t many options available to treat and improve its appearance - and with the right regimen rosacea can be managed very well. It is diagnosed clinically, meaning there is no specific test for it, but rather it is identified by characteristic signs and symptoms.

What causes rosacea?

Sun exposure been proposed to be linked to rosacea, and is probably one of the most important factors in its development. Rosacea often appears on areas of skin that a chronically sun-exposed, although the exact mechanism by which this occurs is not understood or proven.

It is thought that the immune system plays in important role in the development of rosacea, with an inappropriate production of inflammatory and vasoactive peptides (proteins that causes your blood vessels to dilate).

There is also some evidence that microorganisms on the skin could incite inflammation, leading to rosacea. The culprit here is the skin mite Demodex folliculorum, which lives in the hair follicles on human skin and feeds on dead skin cells. It forms a completely normal part of our skin microbiome, but infestation is thought to contribute to rosacea.

Extremes of temperature have also been proposed as a possible exacerbating factor in rosacea. This include both heat and cold, as well as wind and intense exercise.

Finally, spicy and hot foods and alcohol have also been pinpointed as a trigger for rosacea.

How do people usually present with rosacea?

Rosacea is a chronic condition and very common. It tends to affect women more than men, and appear in those over the age of 30. Possibly for quite some time you might have noticed redness and a tendency to flush, or feel that your face is persistently warm and stings. Rosacea is usually most prominent on the face, especially the cheeks, but also affects the chin, nose, and forehead. There is often presence of telangiectasia (tiny spider-like broken blood vessels).

It can be clinically diagnosed if one or more of the follow is present: flushing, persistent erythema, visible blood vessels, or papules and pustules in a central facial distribution.

Depending on your skin type, the presentation can look slightly different, and it is often misdiagnosed in skin of colour. In darker skin tones (Fitzpatrick types IV-VI) flushing or redness is not always as obvious.

Signs to look out for are:

1. the persistent warmth mentioned above, burning or stinging of skin,

2. dry, swollen, rough, or thickened patches of skin,

3. any type of discolouration, or

4. "acne" that does not respond to normal acne treatment.

What are the different types of rosacea?

There are various ways to classify rosacea, summarised below:

1) Centrofacial erythema/Erythemato-telangiectatic - this is just using medical jargon to describe that the redness tends to be in the center of face, effecting the nose and the cheeks.

2) Papulopustular – this describes a type of rosacea that leads to the formation of papules and pustules, again usually in the center of the face. This can sometimes be confused with acne, however unlike in acne you will not find any comedones in rosacea. These papules also differ from acne in that they can form a plaques.

3) Phymatous/Rhinophymatous changes - this describes a characteristic thickening of the skin that can be seen in some rosacea patients. It’s concentrated around the nose. This is often associated with sebaceous hyperplasia leading to very oily skin. This type is also more common in men.

4) “Flushing” - this can be divided into a "wet" type (accompanied with a lot of sweating) or a "dry" type (accompanied with facial swelling).

5) Ocular – this describes involvement of the eyes, and can occur in almost half of rosacea patients. Patients might feel like there is burning in the eyes and that they are very sensitive to light. They might also feel like there is something stuck in the eye, or that their eyes are red and crusty. Small, yellow pustular lesions can be seen in the eye, as well as redness in the conjunctiva. This can be a difficult diagnosis to make.

6) Other - There are other rarer subtypes of rosacea including granulomatour rosacea, rosacea fulminans, lymphoedematous rosacea, or periorificial dermatitis. You will likely need to be seen by an experience skincare doctor or dermatologist to diagnosis this.

How is rosacea managed?

Sun protection is the cornerstone of good rosacea management. While it is important for everyone’s skin, it is particularly crucial in those with the sensitive skin of rosacea which can often be triggered by sun exposure. Anti-inflammatory skincare ingredients as well as antibiotics also have their place in rosacea management. Skincare routines should be kept simple, non-irritating, and gentle. Laser treatments are also available, especially for those with dilated blood vessels.

A common outline of a good management plan is as follows. The first two steps form the foundation and maintenance of keeping your rosacea under control, but if you need more specialist input with prescription creams or medications, always seek advice from your doctor.

• Avoid triggers

  • UV protection is key - use physical sunscreen (organic sunscreens can be more irritating to rosacea skin)

• Good skincare

  • Avoid irritating products like toners or exfoliators

  • Use good, gentle moisturiser frequently. The skin barrier is disrupted in rosacea, leading to increased water loss from the skin.

• Topical treatments

  • Metronidazole, an antibiotic, has an anti-inflammatory effect and is used for this reason in rosacea. It is prescription and needs to be used as directed by your doctor.

  • Azelaic acid, brimonidine, retinoids, and other ingredients are also used.

• Laser or Intense Pulsed Light treatments

• Systemic treatments

  • Tetracyclines (another antibiotics) are commonly used, again for their anti-inflammatory effect. Beta-blockers, because they can constrict the blood vessels in the face improving the redness and flushing, are also used.